Smiling depression: the hidden disease
By Norman Araiza (May 5, 2006)


"It's as though the sun never shines in my mind. It's dark and grey and I just don't care anymore." This is a quote from a former client who had suffered with depression for many years before being referred to me for treatment. When he walked into my office accompanied by a friend, I took one look at him and knew he was depressed. His appearance was shabby and unkempt, and he rarely looked up from the floor. In contrast, imagine a person who appears to be very social, happy, upbeat and gregarious but retreats from social gatherings to the privacy of his or her home and breaks into tears or loses him or herself in cloistered drinking. These are both examples of clinically depressed people. It's not their fault they are depressed, yet both may blame themselves for the state they are in, never thinking they have a physical condition that is highly treatable.

The latter example, which may go on for years without treatment, is the private world of the "Smiling Depressed." These individuals may think that depression is a sign of personal weakness, of poor moral character or of a lack of desire to get better and on with life. What they probably do not understand is that depression is not just a state of mind. It is a physical, medical condition brought on by a chemical imbalance in the brain or changing levels of hormones that manifests itself with psychological correlates. This may explain why many people first experience depression during puberty and in later life during menopause or its equivalent in men, andropause.

There are many types of depression, but sadness at some level is a hallmark of the disease. Yet, in some individuals, sadness may be covered up with explosive anger. Other characteristics include anxiety, chronic fatigue, the inability to find joy in activities that were enjoyable in the past, sleeping disorders, feelings of hopelessness and despair and loss of libido. The symptoms go on. In general, if you have been sad for more than two weeks, you may be depressed. It's the most common of all psychological maladies, occurring in up to 17% of adults. Statistics tell us that it is almost twice as common in women than in men, but those ratios maybe misleading because of the denial factor in men and their hesitancy to seek treatment. For many, it ends in suicide. More women than men attempt suicide, but men seem to be better at it. Often, depression goes untreated, largely due to the attitude of the sufferer.

"Smiling depression" is a term used to describe individuals who suffer from depression; however, because of their inability to accept their condition they attempt to mask or ameliorate the symptoms by putting on a happy face, trying to appear upbeat, jovial and overly social. Unfortunately, there is another side to this disorder of which only their intimates may be aware. Depressive disorders result from abnormal levels of certain neurotransmitters in the brain. What is not fully known is whether an event that triggers the depression causes the imbalance in the brain or whether the imbalance brings on the depression. 

What is known, however, is that depression is a combination of biological, genetic and psychological factors. At the biological level, depression results from the chemical imbalance in neurotransmitters in the brain. Genetics plays an important role, particularly in bipolar disorder, commonly referred to as manic/depressive disorder. This disorder is characterized by extreme mood swings or episodes of elation, rapid flight of ideas, optimism and anxiety and can last from hours to up to a week at a time. This period is usually followed by depression or anger that seems to grow from nothing. Obviously, these individuals have a history of difficulty in interpersonal relations. 

As an attempt at self-medicating, bipolar individuals often resort to alcohol or other drugs to find relief, particularly from manic episodes. As a result, depression is frequently hidden by the more obvious alcohol or drug difficulties. 

In my experience, what first appears to be a periodic alcoholic (one who does not drink between manic episodes) often times is actually an individual suffering from bipolar depression, which can be very effectively treated.

Psychological factors such as poor coping mechanisms, psychosocial attitudes and self-esteem issues may be predisposing factors as well. As in any disease, there is not a single cause for a depression. Nor are there depressive reactions that exist in the absence of physical manifestations. They go hand in hand, body and mind. You cannot have a healthy body without a healthy mind, and vice versa. A person might be symptom-free for some period of time, but psychological changes triggered by a stressor at work or school or in one's personal life bring about depression. The individual may or may not know what event triggered the depression. However, research has shown that it is often some form of serious threat or significant loss. The following are the most common causes for major depression: unemployment, family history of depression, death of a loved one, financial difficulties, poor self-esteem, a pessimistic view of oneself and the world, other chronic illnesses and loss of a relationship.

Often times, depression is unconscious. Family members and others close to the person may be aware that trouble is lurking or that the individual is somehow not in touch with what is happening in her or his life. As a result, this type of depression commonly is expressed through chronic fatigue, illness, physical complaints, insomnia and even marital problems, which are somehow more palatable to the patient. Clearly, depressive disorders are not something that can be "willed away," nor are they something that can be improved by merely "pulling oneself together." In fact, taking a vacation may actually make things worse for someone with a depressive disorder.

The history of the treatment of depression reads like a horror story and includes burnings at the stake and frontal lobotomies. These days, we have a far better understanding of the condition. The good news is that this condition is highly treatable. Eighty percent of those treated do get better. Treatment usually involves antidepressant medication aimed at the chemical imbalance. Thankfully, we have a host of very effective medications that replace the neurotransmitter or hormone that is lacking. Following a two- to three-week build-up period the patient usually feels better. Concurrent counseling or psychotherapy directed at recognizing the triggers, working through emotions and learning new ways of dealing with them is an essential part of treatment and prevention.

Simply put, depression is often the result of some unexpressed emotion from some event in a person's life that seems to create a chemical imbalance in the brain. It requires a great deal of psychic energy to keep the emotion unexpressed, usually below the conscious level, so there is little energy available for normal functioning.

It's important to know that it is not the fault of the individual who suffers from the disease. He or she did not cause it. Sufferers are only responsible for the condition after they become aware of it and still fail to seek treatment. Awareness, as always, is the first step in recovery. The decision to seek assistance is the second step.

Norman Araiza, MA is a US-trained psychotherapist enjoying a limited practice in San Miguel. He can be reached at 152-5449 or nearaiza@hotmail.com